Va Will Overhaul Surgery Standards

``We are reviewing the system with the intent to improve it,`` said Dr. Francis E. Conrad, the VA`s newly appointed director of medical quality assurance. ``It reflects a dissatisfaction with past efforts.``

The action follows disclosure by the Fort Lauderdale News and Sun-Sentinel that more than a dozen VA cardiac surgery programs repeatedly have reported excessive death rates or dangerously low caseloads.

(BU) Using a surgeon`s death and complications rates as evidence in disciplinary proceedings.

(BU) Cracking down on cardiac surgery units that fail to perform sufficient operations to ensure proficiency.

``We have to identify problems and show that there is no repetition,`` said VA Chief Medical Director John W. Ditzler. ``Quality assurance is a national problem.``

The monitoring of cardiac surgery is the most sophisticated quality control program in the VA, the nation`s largest health care system. Heart operations are regulated by a panel of physician consultants that meets twice a year to review deaths.

But a News and Sun-Sentinel investigation revealed that more than 80 percent of these fatalities escaped scrutiny because VA consultants adopted lax screening guidelines -- and frequently ignored them.

The guidelines, in force since the mid-1970s, require outside audits only in hospitals reporting heart surgery death rates above 10 percent, twice the VA`s overall average. VA officials now concede the audit formula is too crude to ensure high quality medical care.

``It (audit guidelines) will be more scientifically based,`` said Conrad. ``We are in the process of establishing a task force to establish (death) norms and standards.``

VA officials also are stripping the cardiac surgery consultants -- who conducted only about half of the 59 death audits that should have been performed between 1978 and 1982 -- of the authority to decide which hospitals require scrutiny.

While the consultants` committee will continue to advise the VA on policy matters, the audit process will be controlled by officials in Washington, Conrad said.

Just how many heart surgery deaths are too many has yet to be established, however.

Ditzler said hospitals reporting mortality in excess of 5 percent should be audited. But he quickly noted that doctors must take into account the type of heart operation and the patient`s age and severity of illness before drawing any conclusions.

``I have a bitter, violent bias against the use of statistics,`` he said. ``You have to know the types of patients.``

VA officials produced a May 1984 Department of Defense document that mandates heart surgery audits when deaths reach 20 percent -- twice the threshold now used by the VA.

The DOD guidelines include only coronary artery bypass surgery, considered the least risky of heart operations. Many civilian hospitals have reported bypass death rates under 3 percent in recent years.

Despite the controversy, VA officials are expanding their use of statistics to ferret out medical malpractice.

The VA plans to compare death and complications rates of individual surgeons to their peers and use these findings in disciplinary actions. In the past, the VA has simply collected overall gross mortality figures by hospital.

VA officials also are planning to crack down on -- and perhaps close -- heart surgery units that fail to perform at least 100 procedures annually -- the minimum number VA considers necessary to ensure competence.

A News and Sun-Sentinel analysis of VA statistics confirmed that heart surgery programs failing to meet volume safety standards reported significantly higher mortality than large programs between 1973 and 1983.